Notes from Past trips

The team arrived in Tel Aviv on the morning of November 29^th, 2008, and traveled directly to Tulkarm, in the northwestern West Bank. The afternoon was spent screening patients at Thabet Thabet Hospital, the Government Hospital in Tulkarm. An additional screening was performed Sunday morning December 1, 2008. A total of approximately 120 patients were screened. The Cleft Team then performed 34 operations from November 30 to December 5, and then proceeded to Ramallah, where the second annual Palestinian Cleft Society meeting was held on December 6th.

During the week, Lynn Fox, Christine Beagle, and Daniel King, had their own very busy agenda.  They initially participated in both of the half-day screenings (November 29^th and 30^th) and were accompanied at all times by local Speech Pathologists, Nurses, and Audiologists. This was carefully orchestrated in order to maximize time spent teaching local practitioners.

On Monday morning, December 1st, 2008, Lynn Fox, Christine Beagle, and Daniel King began an itinerary that included travels to Jenin, Nablus, Ramallah, Jericho, Jerusalem, Bethlehem, and Hebron.  At each site they gave lectures, with demonstrations, that were attended by Speech Therapists and Audiologists, as well as social workers, nurses and doctors. In particular, during their visit to the Jericho Government Hospital, they gave lectures that were attending by over 20 physicians from the Jericho District.  During these visits to hospitals, the three also screened patients in multiple hospitals and clinics, making recommendations for speech therapy, hearing and feeding issues. At all of these screenings, local speech therapists and audiologists were present.

The second annual meeting of the Palestinian Cleft Society, held on December 6^th, 2008 entitled “Improving Speech Outcomes in Patients with Cleft Palate,” was attended by nearly 80 people, a significant percentage of whom were Speech Therapists (38). Importantly there were several medical students, four of whom were from Ben Gurion University in Beer Sheva, Israel, as well as Palestinian medical students from An-Najah University in Nablus, West Bank.

All of the talks approached the issues of speech outcomes from the particular angle of the discipline presenting. The talk given by the Oral Surgeons, Drs. Abughazaleh, and Sandoval, for example, examined the effects that orthognathic surgery has on speech outcomes. Each of the talks was translated into Arabic either by the speaker herself/himself, or by a local practitioner from the same discipline. This allowed a more robust conversation among the participants.

Dr. Josh Demke’s talk was translated into Arabic by an Otolaryngologist from Jenin, Dr. Nasr Najar.  The talk given by Dan King, was translated by Omar Sharifa, an Audiologist from Ramallah.  The two talks given by Lynn Fox, a Speech and Language Pathologist, were translated into Arabic powerpoints by Itaf Arafat, a Speech and Language Pathologist, from the Jerusalem area, and to the audience by Hamine Al Sheikh, a Speech and Language Pathologist from Ramallah. The feeding presentation given by Christine Beagle, was also translated by Hamine Al Sheikh.  These translations grew out of personal relationships developed during a very full week of presentations.

The concurrent sessions for speech therapists, audiologists and surgeons were all well-attended, and were used to reinforce didactic points made during the lectures, in a more informal environment.  In particular, during the Surgeons’ Session, members decided on a position statement from the Palestinian Cleft Society that any foreign surgeon who operates in the West Bank and Gaza should be accompanied by a local surgeon.  No surgery should occur without a local surgeon present during the operation. The Society has since adopted this as an official position.

The entire conference proceedings were telecast to Gaza and to Amman, Jordan through a Skype connection.  The participants in Gaza were at Shifa Hospital.  The participants in Amman were at the University of Jordan.  All future conferences will involve teleconferencing with Gaza and Jordan.

In sum, the second annual Palestinian Cleft Society Conference was a success. The fact that 38 Speech Pathologists, a majority of the practicing speech therapists on the West Bank (out of a total of 44), were present, is an indication that the subject matter delivered will have a significant impact on speech therapy outcomes in children with clefts in the years to come. In addition, the time spent during the week by the team of Lynn Fox, Christine Beagle, and Daniel King, solidified relationships, and on a personal level impacted both these practitioners, as well as their counterparts in all the large cities of the West Bank.

John van Aalst M.D.

Notes from a Speech Pathologist

Speech, Feeding, and Audiology spent all day Saturday (11/ 29) and Sunday morning (11/30) at the Tulkarem hospital evaluating patients and screening for surgical and/or therapeutic needs.  On Sunday afternoon, I provided a lecture on speech issues at the Tulkarem hospital.  The feedback we received all week from people who attended our presentations was that they were not given enough time in advance of the presentation to gather a larger audience.

Later Sunday, I traveled to Ramallah to visit with Itaf Arafat, a speech-language pathologist who teaches students studying to be Speech-Language Pathology assistants at the Ramallah Women’s Training Center and Educational Sciences Faculty.  Since the graduates of this program provide most of the speech-language pathology services in the West Bank, Itaf tries to provide them with as much training as possible

On Monday, I toured the Ramallah Women’s Training Center and Educational Sciences Faculty and met with the faculty and staff.  I also gave a presentation about working with children with cleft palates to the current class of speech-language pathology assistants.  I spent the afternoon with them, helping to answer their questions and learning more about the environments in which they will someday work. While I was there, I also evaluated a patient who came into their training center.  He was a 7-year old boy with a repaired cleft palate and other craniofacial anomalies.  He was not allowed to attend school because he was thought to be unintelligent due to his significant speech intelligibility issues.  Since I was concerned about his feeding and hearing issues, I arranged for him to visit us as Ramallah’s Government Hospital the next day.

On Tuesday, I re-joined the Feeding Specialist and Audiologist to visit the government hospital in Ramallah to evaluate local patients.  We referred several for surgeries and speech therapy.  Later that day, we went to Jericho.  We gave a presentation on cleft care to a large audience with a good deal of audience participation and interest.

On Wednesday, we started our day in Bethlehem where we evaluated a good number of patients (most of whom had just had surgeries with the other cleft team that was visiting that week or who were being evaluated to determine need for surgery or therapy).  We next travelled to Hebron for the afternoon where we met with the hospital director.  The hospital social worker was able to contact one patient who came in to see us and we were able to speak with several members of the hospital staff about cleft care.

On Thursday, we visited the Red Crescent Society building where much of the outpatient speech therapy and audiology for the surrounding areas is carried out.  We toured the facilities (including the preschool and high school for deaf children) and consulted with several patients who were scheduled to be seen that day.
On Friday, we met with the main speech-language pathologist and audiologist from the Red Crescent Society to prepare for the cleft care conference on Saturday.  They were invaluable for translation of our lectures and most importantly for giving us insight into the practical issues that face patients and therapists in the region.

On Friday, we met with the main speech-language pathologist and audiologist from the Red Crescent Society to prepare for the cleft care conference on Saturday.  They were invaluable for translation of our lectures and most importantly for giving us insight into the practical issues that face patients and therapists in the region.

On Saturday, we took part in the Palestinian Cleft Society Conference where we presented information on speech, feeding, and audiology related to cleft care.

Lynn Fox, MA, Med, Chapel Hill, NC

Notes from a feeding specialist

I had the amazing opportunity to travel to the West Bank this December with Dr. van Aalst’s cleft mission as the team’s feeding specialist.  Upon our arrival, the whole team went to Tulkarm where we conducted screenings for surgery.  It was difficult to see so many families show up knowing that only a percentage of them would be able to get a surgery in the upcoming week.  I was immediately struck by the courage and creativity of these mothers struggling to feed their babies with open clefts with no support and no education.  It was so rewarding to be able to provide them with specialized bottles, knowing what a difference it would make in their child’s health and growth!

Once the surgical candidates were selected, I left Tulkarm along with our other speech therapist and audiologist to travel from city to city to educate people about cleft care.  It is truly difficult for me to put our experience into words.  Over the course of the week, we visited hospitals in Jenin, Nablus, Ramallah, Jericho, Bethlehem, and Hebron.  Everywhere we went, we were met with such an overwhelming welcome.  Everyone was incredibly eager to learn.  We were able to present our information to groups of anywhere from 2-30 people.  Our audience varied from parents, to nurses, to local therapists, to doctors, and even to hospital directors!  We were able to build strong relationships with several local therapists in particular, spending time in their clinic assisting them with some of their cases.  I have maintained close contact with 2 of them, and hope that I can continue to be a resource and a support to them in the coming years.

As the feeding specialist, I was especially struck by the lack of resources available to families.  I learned that a cleft bottle that typically costs $7-10 in the United States, can cost more than $70 in Palestine!  It made me feel somewhat helpless to know that even if I armed people with information, in many cases they still wouldn’t have the supplies they need to provide optimal cleft care.  I was able to distribute over 100 cleft bottles as well as handouts describing their use, but I know that that is not enough.  Another thing that really stood out to me was the isolation of the medical professionals that are attempting to provide care.  With the political situation as it is, it is very difficult for people to collaborate and build truly team-based care.

I feel that our time in Palestine was incredibly productive.  I was able to provide tangible, immediate assistance by providing families with specialized bottles, as well as providing education to local professionals that will hopefully have a more long-reaching effect.  Although we made an impact, there is much work still to be done.  The Palestinian people need continued support and assistance to build a true Cleft Palate/Craniofacial team that is equipped with the knowledge and resources needed to implement good cleft care independently.  Thank you for providing the funding needed to make this trip possible.  I look forward to hearing about continued progress in Palestinian cleft care through future missions!

Christine Beagle, MA, Durham, NC

Notes from an audiologist

First of all, I feel very lucky to have been chosen as to be a part of such a wonderful organization and amazing cleft mission team, as the team audiologist.  I was one of three individuals to have the opportunity to travel to numerous cities in the West Bank and present/teach physicians, nurses, speech pathologists, audiologists, parents, social workers and other healthcare providers on the challenges typically found with children who have cleft lip/palates or other craniofacial anomalies.

During my visits to the government hospitals of Jenin, Nablus, Ramallah, Bethlehem, Jericho, and Hebron I feel as though I was able to address the complications of hearing loss most often found in children with clefts.  It was very encouraging getting active feedback and questions regarding my presentation, as most individuals were not aware of the high incidence of hearing loss and middle ear problems associated with cleft palates.  I believe that it was beneficial for this group, consisting of myself (an audiologist) and 2 speech pathologists (one speech focused, the other feeding focused) to travel throughout Palestine and teach about cleft care.  We were able to reach/educate a far greater number of people who are actively participating in the care of patients with clefts than if we would have only presented at the 2^nd Annual Conference of the Palestinian Cleft Society.  I believe this community outreach and teaching, along with future guidance is a great step in improving cleft patient care.

At the 2^nd Annual Conference of the Palestinian Cleft Society, I was able to speak to the general audience about hearing assessment of children with clefts; possibly more important was the time I spent with the two audiologists that attended the conference.  Although this was a small group, I was able to provide them with information that was clinically applicable, that they can easily apply to their audiology practices.  I have been lucky enough to keep in touch with them and continue to help them with cleft patients in their practices.

At the Palestinian Cleft Society Conference, I felt there was a great desire by the attendees to improve the care that children with clefts receive.  I feel that continued support, education, and training is paramount to overcome the challenges that the health care providers in Palestine are facing.  Audiology is an area that presents its own unique challenges.  There are only three Audiologists in all of Palestine. In order for these Audiologists to perform reliable diagnostic audiological testing, expensive equipment and controlled listening environments are necessary.   This will take time, money and commitment. I also feel that an overall improvement in the coordination of Otolaryngology and Audiology services would benefit the cleft population greatly.  This definitely coincides with what was agreed upon by the attendees at the Conference: a self sustained Palestinian Cleft Team, consisting of Otolaryngologists, Speech Pathologists, Audiologists, Nurses, Orthodontics, Oral Surgeons, Plastic Surgeons, and Dentistry is vital to the continued improvement of cleft care in Palestine.

Daniel King, AuD, CCC-A, Durham, NC